Behavior Canine O V R S

Document Sample
Behavior Canine O V R S Powered By Docstoc
					                    CANINE BEHAVIOR CONSULTATION QUESTIONNAIRE
                Oakland Veterinary Referral Services, 1400 S. Telegraph Rd, Bloomfield Hills, MI 48302
                              Phone 248-334-6877 fax 248-334-3693 behavior@ovrs.com
                                              Theresa DePorter, DVM
General Information
Today’s date:                                                     Date and time of consultation (if scheduled):
Name:                                                            Email:
Address:                               City/Town:                                   Zip Code:
Phone: Home: (       )                Business: (      )    ext:       Mobile/other (      )          Fax: (    )
Veterinary Clinic                      Veterinarian’s Name:                        Clinic phone: (       )
Who referred you to OVRS?

Pet Information
Pet’s Name:                                                        Date of birth:      Age, estimate age if unknown:
Sex:               If neutered, at what age?:         Breed or Description:                   Color:        Weight:
Briefly describe your dog’s personality (check all that apply) quiet ; calm ; confident ; excitable ; bold ; unruly            ;
stubborn ; shy ; fearful ; intense ; aggressive ;other                   Please describe:

Instructions
        Please complete this form carefully. Include all relevant information. Do not duplicate information
        Watch directions closely – not all questions are required for every pet. Skip sections as directed. When check boxes are
         available check all that apply, elaborate as needed and use NA for not applicable.
        Return completed forms 3 business days before your consultation or as soon as possible
        Email is preferred behavior@ovrs.com but you may also return it by fax (248) -334-3693
        This form is designed to be completed on a COMPUTER – if completed by hand you may need to write/type answers on
         additional paper. Detailed information is critical for Dr. DePorter to diagnose and recommend a treatment program
        To avoid losing your information; please remember to “save” often and print a copy when you complete this form
        This questionnaire is being completed by
        You may bring all involved pets. We may request specific pets to accompany on follow-up visits.

Your pet’s early history
Age obtained:       From where did you obtain this pet?
Breeder’s Name or Shelter: (if applicable):
Describe previous home / homes (if known):
For what reason did you obtain this pet? (check all that you feel are appropriate): companion : protection ;
         competition (agility, obedience, field)   ; breeding ; show/conformation ; assistance/service dog          ; other
         Please describe:
Behavior of parents or littermates (if known):

The Home Environment
List each family member living in the home (include children):
Name                                                    Relationship      Sex Age     Describe how they get along with dog




List all other pets in the home:
Name                          Breed                   Sex        Neutered?    Age     Describe how they get along with dog


                                                                                                                                    1
Principle Complaint
Describe your pet’s primary problem

When did the problem begin?

What age was your pet when this problem started?

Describe any changes in the home or the pet’s health when the problem first started:

What do you think caused the problem?

Describe the problem, beginning with the most recent incident:


Describe the first incident and any other pertinent incidents:


How often does the problem occur?


Describe duration of the problem (check all that apply):
         new, recent problem ; since puppy ; since acquired ;
         occurring for weeks ; occurring for months ; occurring for years ;
         improving ; getting worse ; intermittent ; unpredictable ; Please elaborate:

Describe severity: mild ; moderate ; severe ; will not be able to keep if problem persists ;
         will euthanize if problem persists will relinquish pet to another home if problem persists      ;

What has been done so far to try and correct the problem?


What has been the dog’s response?


List any techniques that have been at all successful:


List any techniques that have made the problem worse:


List any drugs (include dosage) tried for behavior problems and the dog’s response (dates given, benefits, side effects):
Medication                         Strength     How often given When given        Purpose/comments




                                                                                                                            2
List any other dietary treatments, supplements, or remedies and the dog’s response (effects, side effects):

Diet and nutrition
Type of food:       What is your pet’s favorite food?
Describe your pet’s appetite: voracious ; picky ; average        ; good   ; poor   ; other
Describe your pets feeding routine:
Type of treat(s)?

Activities
Describe the usual daily schedule for your dog and the family:


Type, length and number of exercise / play sessions with your dog and with which family members:
Favorite game(s):
Favorite toy(s):
Where is your dog’s preferred sleeping spot / daytime?
Where does the dog sleep at night?
Have you ever used a crate or pen for confinement?         Do you still use a crate or pen?
Describe the dog's reaction to being crated or confined:
If you no longer use a crate or confinement, when and why did you stop?
Describe the crate or confinement area and its location:

Medical Screen
Describe any other medical problems:
List ALL medication/supplements your pet receives currently or frequently:
Medication                       Strength    How often given When started          Purpose




Has your pet had any laboratory tests (blood, urine, X-rays etc.)?       If yes, indicate any abnormal findings:
Does your pet drink excessively?         If Yes, describe (how often, how much):
Describe any known arthritis or other painful conditions?
Describe any observed deficits in your pet’s senses?
How often per day does your pet defecate?           Describe your pet’s stools (check all that apply): normal ; constipation ;
         soft / diarrhea   If abnormal, describe:
How often per day does your pet urinate?          Describe your pet’s urination: (check all that apply) normal ; infrequent ;
         excessive frequency ; excessive volume            If abnormal describe:

Departure Behavior Screening
Describe how your pet is confined, restricted or crated when you leave the home
How long is the dog left alone on the average day and when?
At what times of day is your dog most commonly left alone?
How does your dog react when you prepare to leave?
Is the dog ever alone outdoors? Yes No          How often?       How long (average)?
          How is your dog contained/restricted when left when outdoors?
          How does your dog react to being left alone outdoors?
                                                                                                                                 3
Does your dog exhibit any behavior problems when you leave your dog alone                                        YES     NO
IF YES, PLEASE CONTINUE. IF NO, SKIP THE NEXT SECTION, PROCEED TO HOUSETRAINING SCREEN
Describe your dog’s behavior when left alone at home:
How does your dog react when you prepare to leave?
How does your dog react at the time of departure (as the last person prepares to leave)?
Does the dog act differently depending on who is the last to leave? Yes No        If yes, describe how the dog reacts differently
         with each family member:
What is the dog’s reaction at homecomings?
How does your dog react when left alone in the car?         What is the longest that you have left your dog in the car without
         problems arising?
What techniques have you used so far to try and improve the problem?          List each technique and the dog’s response:
Have you recorded video or audio of how your dog behaves when your dog is left alone Yes No
         Describe what you observed


Housetraining Screen
Where is your dog’s primary location for elimination?
Describe how your dog signals when it needs to eliminate:
Do you accompany your dog outside for elimination? Yes        No

Is your dog completely housetrained?                                                                            YES     NO
IF NO, PLEASE CONTINUE. IF YES, SKIP THE NEXT SECTION AND PROCEED TO TRAINING
Does your dog soil in the home with urine ; stools ; both                           How often?
Does your dog soil in a specific location ; multiple locations ; random locations
What are the most likely locations for soiling?
When is the dog most likely to housesoil?
Does your dog housesoil when family members are at home? Yes No
         If yes, describe when:
Does your dog housesoil while you are watching? Yes No
         If yes, what is your reaction and your dog’s response?
What do you do when you catch your dog soiling in an incorrect location?
What do you do when you find urine or stool that has been passed in the improper location?
         What is your dog’s response?
Does your dog urine mark (lift leg / small amounts) outdoors? Yes No If yes, describe:
Does your dog urine mark indoors? Yes No If yes, describe:
Do you confine your dog to a crate, room or pen? Yes No
         If yes, does your dog eliminate in the crate, room or pen? Yes No
Does your dog leak urine or lose control? Yes No          If yes, describe when and where:

Training
Has this pet had obedience training, professional training or behavioral assistance?                            YES     NO
IF YES, PLEASE CONTINUE. IF NO, SKIP THE NEXT SECTION, PROCEED TO FAMILY TRAINING
Professional training
Has this pet had obedience training, professional training or have you sought professional behavioral assistance? Yes No
         If yes, describe;
Puppy class ; Training class for adult dogs ; private instructor ; I trained my dog myself ; Other           Describe:
At what age was your dog first enrolled in training classes.
Did you enroll in any additional classes and at what age?
Describe the classes including the school(s) or instructor(s)
         Describe the type of training?
         Check all that apply: Reward based (praise) ; Reward based (food)        ; Clicker training ; Assertive /dominance         ;
                                                                                                                                    4
         Aversive/corrections ; Lure training ; Other
Do you continue to train?         If yes describe who trains, type of training and how often:
Describe any specialized training you have done with your dog (obedience, conformation, agility, flyball, hunting, retrieving,
coursing, protection etc):
Have you used a trainer, veterinarian or behavior specialist for the problem for which you are seeking help today?
         If yes, describe trainer, type of training and recommendations:
Describe all recommendations are you still following:

Family training
If you trained your dog yourself or in addition to training with professional assistance, please describe what you have done:
Describe the type of training?
           Check all that apply: Reward based (praise) ; Reward based (food)          ; Clicker training ; Assertive /dominance   ;
           Aversive/corrections ; Lure training ; Other
What books have you read and implemented:
What type of training has been most successful?
Did any training technique make problems worse?
Describe your dog’s learning ability:
List family member(s) with most control:                                     List family member(s) with least control:
Describe any tricks your dogs knows

Please indicate how your dog responds to the following commands:
                             Excellent/                  Fair, easily
                                             Good                            Poor          Never           Comments/describe
                              reliable                   distracted
Sit
Sit-focus 1 minute
Sit-focus 5 mins or more
Down
Down/stay 1 minute
Down/stay 5 mins or more
Come (indoors)
Come (in yard)
Come (in park, public)
Walks on loose leash
Walks on loose leash,
distraction
Give / drop toy
Give / drop stolen item
Go to bed, mat or crate
Watch/ “look at me”


Punishment / Discipline / Corrections
Have you ever used any of the following for punishment or training? (mark all answers that apply)
                                                                        Improves        Worsens
                            Never tried       Tried       Use often                                        Comments/describe
                                                                        behaviors      behaviors
Verbal reprimands
Physical punishment
Muzzle grasp
Lifting off ground
                                                                                                                                  5
Pinning/alpha rolling
Noise shaker can / chains
Noise ultrasonic/siren
Water Sprayer
Citronella / Air Spray
Booby traps / repellents
Time-out
Shock collar
Citronella collar
Anti-bark collar
Containment collar
Buckle collar
Head halter
Prong collar
Choke/chain collar
Body harness

Has any punishment been effective? Yes No              If yes, indicate what worked best and in what situations:
Has any punishment made the problem worse? Yes No                   If yes, describe punishment and dog’s reaction:
Has punishment ever led to threatening behavior or aggression? Yes No                 If yes, describe:
Does your dog respond differently to punishment from different family members? Yes No                   If yes, describe:
***Please bring all training devices, collars, halters and harnesses you have for your dog to your appointment***


Handling
Please characterize your dog’s reaction to the following. Describe known responses; it is NOT intended for you to attempt each
one:
                                              Accepts       Accepts                Threatens/      Cannot
                      Unknown Enjoys                                    Resists                                Comments/describe
                                              willingly    reluctantly             aggressive      attempt
Nail trimming
Ear / eye cleaning
Brushing
Bathing
Brushing Teeth
Rubbing belly
Patting head
Hugging / kissing
Being lifted
Grabbing collar
Giving medication
Removing food,
treat or preferred
toy
                             To avoid losing the information you have entered,
                                 save & print a copy of your answers now


                                                                                                                             6
Reactivity –
Indicate how your dog reacts to each of the following:
                        Calm Friendly Excited Ambivalent               Confused      Fearful     Aggressive    Comments/describe
Familiar dogs
Unfamiliar dogs
Squirrels, wild
animals
Cats

Children
Familiar people
Unfamiliar people
approaching at home
Unfamiliar people
approaching away
from home
Visitors to the home
arriving at door
Car rides
Thunderstorms /
fireworks
Bikes
Describe any reactivity problems in more detail:

How long after exposure to these events is finished, does your dog settle down (i.e. back to normal)?

If possible and safe, please make a short video clip of your dog demonstrating reactivity to
any of the above stimuli. These may be short digital videos or may be on traditional
videotapes.


Does your dog exhibit fear of noises                                                                            YES    NO
IF YES, PLEASE CONTINUE. IF NO, SKIP THE NEXT SECTION, PROCEED TO MISCELLANEOUS
Describe which noises and your dog’s reaction:
Fears, phobias or anxiety of locations or situations       If yes, describe:
Shyness/timidity (non-aggressive): e.g. ears back, cowering, tail tucked, shaking, retreating, hiding, etc.
         If yes, describe situations not previously discussed:
Anxiety (non-aggressive) If yes, describe here (or under principle complaint):
How long after exposure to these events is finished, does your dog settle down (i.e. back to normal)?


Miscellaneous:
Describe your pet’s response to the following. If undesirable, please comment

                                    Does     Does occur       Does occur,          Reason for
                                     not      but not a       would like to        visit today            Comments/describe
                                    occur      concern          improve

Vocalization: Barking
Vocalization: whining
Vocalization: howling
Jumps up (owners)
                                                                                                                                   7
Jumps up (strangers)
Won’t come when called
Nips / grabs hands with mouth
Only listens when feels like it
Pushy / demanding
In rooms where not permitted
Overly affectionate
On furniture where not allowed
Chasing
Stool eating
Hunting/predation
Garbage raiding
Food stealing
Eats non-food items
Destructive chewing
Licks Objects
Excessive grooming
Staring
Star gazing
Fly chasing
Light chasing
Tail chasing
Digging
Masturbation
Mounting
Roaming / running away
Night waking
Wakes up family members

Aggression Screen
Has your pet ever displayed any of the following? Threat displays ; Growling ; Bite attempts ; Bites
If yes to any of the above, how would you describe the problem? Getting worse ; Staying about the same   ; Better   ;
Resolved
How many bites have occurred?          (Describe all bites fully in questions below)

SUMMARIZE BITE HISTORY
Date (may Situation    Who was bitten (name,                    Relationship              Bite break      Comments
be approx)             person or animal)                        (familiar, stranger)      skin?
                                                                                          Yes No
                                                                                          Yes No
                                                                                          Yes No
                                                                                          Yes No
                                                                                          Yes No
                                                                                          Yes No
                                                                                          Yes No

                                                                                                                        8
Describe your pet’s response to each of the following situations. Describe known responses; do not attempt each one.
                                                                                        Bites,      Bites,       Comments
                                                                   Growls/
                              Enjoys Tolerates Cowers                          Snaps      no       broken
                                                                   snarls
                                                                                        injury       skin
Petting
Handling/restraint
Eating food or treats
Approach while playing
with toys
Chewing stolen objects
Disturbed while resting
Strangers on property
Strangers off property
Strangers arriving indoors
Unfamiliar dogs on
property
Unfamiliar dogs off
property
Other family pets

If possible and safe, please make a short video clip of your dog demonstrating reactivity to
any of the above stimuli. These may be short digital videos or may be on traditional
videotapes. Do not put anyone at unnecessary risk.

Does your dog demonstrate any threats or aggression (growled, snarled, snapped or bitten)?                 YES NO
IF YES, PLEASE CONTINUE. IF NO, SKIP THE NEXT 2 SECTIONS AND PROCEED TO CHECKLIST FOR BEHAVIOR APPOINTMENT
What is the potential for injury? None, or preventable ; minimal ; moderate ; severe             describe:
Is aggression the primary reason for today’s visit?                                                   Yes No
If necessary, could you predict and avoid or prevent all situations in which aggression might arise? Yes No
Is the problem serious enough that you will be unable to keep your pet if it is not improved?         Yes No

Aggression to people:                Is your dog ever aggressive to members of the immediate family? YES            NO
                                     Has your dog ever displayed threats or aggression to strangers? YES            NO
IF YES, PLEASE CONTINUE. IF NO, SKIP THE NEXT SECTION AND PROCEED TO AGGRESSION TO ANIMALS
To whom has your dog displayed aggression?
Describe the first event (when, where):


Describe the most recent event:


Describe the most significant event:


Prior to bites does your pet threaten or show warning signs? Yes No           If yes, describe:
Description of aggression:
          threaten, growl, but no bite ; single bite and grasp but skin not punctured ;
          single bite deep enough to break skin ; multiple bites then stops if stimulus retreats ;
          multiple bites until dog removed from situation ; bite, release and then growl / threaten .
Has your dog’s bite ever caused sufficient injury to require medical attention? Yes No          If yes, describe:
When your dog threatens or attempts to bite, how do you handle the situation?
                                                                                                                            9
         What is the dog’s reaction?
After your dog has bitten how do you handle the situation?
         What is the dog’s reaction?
Describe any technique that seems to improve the problem:
Describe any technique that seems to aggravate the problem:
How would you describe your dog’s attitude when aggressive?
         bold ; protective ; possessive ; outgoing ; fearful ; confused ; other                  If other, describe:
Describe your dog’s expressions and postures at the time of aggression: (e.g. cowering, eyes wide, ears back, tail tucked, hackles
         raised, retreating, hiding):
How has your dog’s aggression changed since the first incident?
Describe how your pet responds to someone at the door:
Describe any precautions or actions you take when someone comes to the door:

Aggression to animals Does your dog ever display aggression to animals?                                            YES   NO
IF YES, PLEASE CONTINUE. IF NO, SKIP THE NEXT SECTION AND PROCEED TO CHECKLIST FOR BEHAVIOR APPOINTMENT
Is the aggression toward: other dogs ; cats ; other           If other, list species:
          If yes, were these animals: other family pets ; strange / unfamiliar animals
          If yes, was the aggression: on property indoors ; on property outdoors ; off property
Describe any pattern; particular species, breed, sex, type, individual that your dog is most likely to threaten or bite:
Describe the first event (when, where):


Describe the most recent event:


Describe the most significant event:


Prior to bites does your pet threaten or show warning signs? Yes No If yes, describe:
Description of aggression: threaten, growl, but no bite ; single bite and grasp but skin not punctured ;
          single bite deep enough to break skin         ; multiple bites then stops if stimulus retreats ;
          multiple bites until dog removed from situation ; bite, release and then growl / threaten
Has your dog’s bite ever caused sufficient injury to require veterinary attention? Yes No              If yes, describe:
When your dog threatens or attempts to bite, how do you handle the situation?
          What is the dog’s reaction?
After your dog has bitten how do you handle the situation?
          What is the dog’s reaction?
Describe any technique that seems to improve the problem:
Describe any technique that seems to aggravate the problem:
How would you describe your dog’s attitude when aggressive? bold               ; protective ; possessive ; outgoing ; fearful ;
          confused ; other          If other, describe:
Describe your dog’s expressions and postures at the time of aggression: (e.g. cowering, eyes wide, ears back, tail tucked, hackles
          raised, retreating, hiding):
How has your dog’s aggression changed since the first incident?




                                                                                                                               10
Checklist for your behavior appointment:
   PLEASE BRING OR EMAIL A PICTURE OF YOUR PET FOR OUR FILE
        (BEHAVING OR MISBEHAVING)

        PLEASE MAKE OR SEND VIDEOS OF YOUR PET DEMONSTRATING ANY RELEVANT BEHAVIORS IF YOU CAN
         SAFELY DO SO.
        PLEASE COMPLETE AND RETURN THIS QUESTIONNAIRE 3 DAYS PRIOR TO YOUR APPOINTMENT
         FAX 248-334-3693 OR EMAIL behavior@ovrs.com
        PRINT AN EXTRA COPY OF THIS COMPLETED FORM NOW. BRING THAT COPY OF
         COMPLETED QUESTIONNAIRE TO THE APPOINTMENT.
        WE REQUIRE 48 HOURS NOTICE TO CANCEL/RESCHEDULE YOUR APPOINTMENT
         WITHOUT LOSING YOUR DEPOSIT
        PLEASE ASK YOUR VETERINARIAN TO COMPLETE THE REFERRAL FORM ON OUR
         WEBSITE WWW.OVRS.COM AND SUBMITT COPIES OF RECENT LABORATORY TESTS
         PRIOR TO YOUR VISIT.

Is there anything else you would like to add about your pet and its behavior? Please include any other information you think is
relevant to the case or your family

Describe your goals and expectations for your dog’s behavior

Describe your goals and expectations for this behavior consultation

Describe how you learn best:

Please help us understand how you learn best – select your preferred methods:
        Demonstration                             Videos
        Opportunity to do it yourself             Handouts
        Verbal explanation                        Books
        Online references



This questionnaire was designed by Dr. Gary Landsberg and Dr Theresa DePorter and may be reproduced only with his written permiss
            They retain all rights to the use of this questionnaire – it may not be distributed, reproduced or used commercially.




                                                                                                                                  11

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:5
posted:11/29/2011
language:English
pages:11